Co-Pay Accumulators Are a Craven Attempt to Accumulate Profit Off the Backs of Patients

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

Imagine, for a moment, going to a restaurant and paying for your meal with a gift card, only to have the restaurant accept the gift card but demand that you pay the full price of the meal again in cash before you can leave. This is, in essence, how many health insurance companies operate when patients attempt to use drug discount coupons to purchase the prescription medications they might otherwise be unable to afford. This anti-patient insurance policy represents everything wrong with the current American healthcare system.

Photo Source: International Myeloma Foundation

In 2018, insurance companies and Pharmacy Benefit Managers (PBMs), such as Express Scripts and CVS Caremark, began implementing what they called “Co-Pay Accumulators” or “Co-Pay Maximizers” (Schmid, 2018). These policies allow health insurers to accept payments made using manufacturer or other private-entity drug discount cards or coupons, but ignore those payments when counting toward the patient’s deductibles or out-of-pocket maximums.

When this occurs, patients will max out the benefits available through those discount cards or coupons and then be forced to continue paying out-of-pocket costs that should have been covered by those manufacturer payments (Brooks, 2020). This allows insurers to “maximize” their profits by refusing to cover the costs of those medications.

Take the case of Larry Gruber (a fictitious name to protect the patient's identity), a fitness coach from Wilton Manors, Florida. For 16 years, Gruber utilized a manufacturer co-pay coupon to help pay for medication to treat his psoriatic arthritis that would otherwise cost $7,700/month. Using Amgen’s co-pay coupon, Gruber was able to receive his medication and meet his deductible and out-of-pocket maximums each year by February, reducing his in-network and prescription medical costs to $0/month for the remainder of the year.

Then, he was switched to a new health insurance plan offered by Oscar HMO of Florida. This plan used a co-pay accumulator program, allowing them to pocket the payment from Amgen and still requiring him to dip into his personal savings to meet his $10,600 out-of-pocket maximum (Chang, 2026).

Photo Source: Institute for New Economic Thinking

If it sounds like highway robbery, that’s because it is.

To understand why these programs exist, we must first recognize one fundamental truth:

The purpose of health insurance companies in the United States is not to ensure that patients can afford healthcare services; their purpose is to make a profit.

The entire private health insurance business model is intrinsically dependent on denying coverage for goods or services that are “too expensive” for the companies and finding other ways to shift costs that should be borne by insurers onto patients.

Co-pay accumulators are a growing problem, as well. According to an analysis from The AIDS Institute, nearly 40% of commercial insurance programs in the U.S. have implemented accumulator programs (The AIDS Institute, 2026).

Photo Source: The AIDS Institute

It’s important to note that co-pay accumulator programs only exist in the commercial insurance landscape—insurance purchased either through an employer or independently. Patient assistance programs and co-pay coupons/cards can ONLY be used by patients with commercial insurance. Medicaid or Medicare patients cannot use them because of a federal anti-kickback law that prohibits manufacturers from offering any payment that might persuade a patient to choose a name-brand drug over a generic alternative when a public health program is the payor (Andrews, 2018). This statute does not, however, apply when the patient has commercial insurance.

Why?

Because government-funded health insurance programs were not created to make profits; they are created to ensure that patients are able to access healthcare services.

For-profit insurance companies argue that co-pay coupons and other types of financial assistance programs “undermine the actuarial structure of insurance plans,” forcing insurers to spend more on prescription medications than they “should” have to pay (Choi e al., 2024). By shifting costs back onto patients, insurers can continue to make profits, while patients can go bankrupt.

And this is the reality for many patients who rely on co-pay coupons and other forms of patient assistance. Most patients who rely on these forms of payment assistance are living with conditions that can be treated only with a limited number of medications, such as Hepatitis C, various types of arthritis, and other chronic conditions, most of which are exorbitantly priced. These patients are also the least able to afford treatment delays, as many of these conditions will worsen over time, crippling or potentially killing the patients (Chang, 2026).

In fact, the patients most likely to have chronic conditions are those least likely to afford it. The prevalence of chronic illnesses is higher in counties where levels of poverty are higher—particularly in the South and in Appalachia (Benavidez et al., 2024).

Co-pay accumulators are a craven attempt to accumulate profit off the backs of patients and manufacturers, and the sooner we implement federal laws banning their utilization, the better.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] AIDS Institute, The. (2026, February). Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026. Tampa, FL: The AIDS Institute: Policy & Advocacy: Healthcare Access: Copays (National). https://theaidsinstitute.org/media/documents/02-27-2026-09-23-55-TAI_2026_Report_final.pdf

[2] Andrews, M. (2018, May 09). Why Can't Medicare Patients Use Drugmakers' Discount Coupons? Washington, DC: National Public Radio: Health Shots. https://www.npr.org/sections/health-shots/2018/05/09/609150868/why-cant-medicare-patients-use-drugmakers-discount-coupons

[3] Bevavidez, G. A., Zahnd, W. E., Hung, P., & Eberth, J. M. (2024, February 29). Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area. Preventing Chronic Disease, 21, E14. http://dx.doi.org/10.5888/pcd21.230267

[4] Brooks, A. (2020, June 18). Copay Accumulator Programs: What Patients Should Know. Santa Monica, CA: GoodRx: Insurance: Health Insurance. https://www.goodrx.com/insurance/health-insurance/copay-accumulator-programs-cms-ruling

[5] Chang, D. (2026, July 07). Copay Assistance Is Meant To Defray Patient Drug Costs. Some Insurers Keep It Instead. San Francisco, CA: KFF Health News: Health Care Costs. https://kffhealthnews.org/health-care-costs/copay-accumulator-adjustment-programs-patient-assistance-insurance-pharma-drugs/

[6] Choi, D., Zuckerman, A. D., Gerzenshtein, S., Katsivalis, K. V., Nichols, P. J., Saknini, M. C., Schneider, M. P., Taylor, P., & Dusetzina, S. B. (2024). A primer on copay accumulators, copay maximizers, and alternative funding programs. Journal of Managed Care & Specialty Pharmacy, 30(8), 883-895. https://doi.org/10.18553/jmcp.2024.30.8.883

[7] Schmid, C. E., II. (2018, August 31). New Accumulator Adjustment Programs Threaten Chronically Ill Patients. Washington, DC: Health Affairs: Pharmaceuticals & Medical Technology: Forefront. https://www.healthaffairs.org/content/forefront/new-accumulator-adjustment-programs-threaten-chronically-ill-patients

CVS Caremark Plays Kicks-the-Can on Yeztugo; Undermines HIV Prevention Efforts

By: Ranier Simons, ADAP Blog Guest Contributor

Benjamin Franklin is credited with the phrase, ‘An ounce of prevention is worth a pound of cure.’ In simple terms, it is easier to prevent a negative outcome from happening than to expend energy repairing damage that has already occurred. This is especially true regarding HIV. Given that there is currently no cure for the virus, it is imperative to prevent HIV transmission. Recent innovations, especially long-acting injectable agents, have expanded the toolbox of HIV prevention. Consequently, the mere existence of life-saving tools is not beneficial if the people who need them are denied access. CVS Caremark recently announced that it will not be adding coverage for Yeztugo (lenacapavir), Gilead Sciences' bi-annual HIV PrEP injectable, to its commercial plans (Beasley, 2025).

Pharma.com | The Economic Times

Yeztugo was approved by the U.S. Food and Drug Administration (FDA) in June 2025, following the successful outcomes of its Phase 3 clinical trials, PURPOSE 1 and PURPOSE 2. Approximately 99.9% of participants remained HIV negative, proving Yeztugo in the trial to be more effective than daily Truvada administered as PrEP (Gilead, 2025). Out of the 2,179 participants in the PURPOSE 2 trial, only two people contracted HIV.

Medicare, Veterans’ Administration, and some Medicaid plans are already covering Yeztugo. In contrast, CVS Caremark has stated that it will not cover the drug in its commercial plans, nor in any of its Affordable Care Act (ACA) formularies. CVS follows the recommendations of the U.S. Preventive Services Task Force (USPSTF) for HIV prevention medications. Presently, USPSTF only recommends daily Truvada (Gilead), Descovy (Gilead), and the bimonthly injectable Apretude (ViiV). Prevention measures recommended by the USPSTF must be covered without any patient cost-sharing. Many in the HIV care community are concerned about Yeztugo ever being recommended by the USPSTF, given the current paradigm of the embattled JFK Jr.-led U.S. Department of Health and Human Services (HHS) (Beasley, 2025).

Photo Source: Metro Weekly

In a statement emailed to the publication Fierce Pharma, a CVS spokesperson explained, “As is typical with new-to-market products, we undergo a careful review of clinical, financial, and regulatory considerations, under the guidance of our external Pharmacy and Therapeutics (P&T) Committee of independent medical experts” (Kansteiner, 2025). Given that Medicare, Veterans’ Administration, and some state Medicaid plans (including California and New York) are already covering Yeztugo, and it has had stellar results in its clinical trials, it is unclear what clinical, financial, and regulatory considerations are of concern. Those in the HIV care community feel CVS’s decision is based on Yeztugo’s list price of $28,000 per year for the two injections. The average lifetime cost of treating a person living with HIV ranges from $420,285.00 to over $1 million (Bingham et al., 2021). Thus, in the long term, preventative treatment would appear cost-effective.

Notably, CVS Caremark is currently embroiled in legal disputes. Chief Judge Mitchell Goldberg, a Philadelphia federal judge, issued a ruling ordering CVS Caremark to pay a $289.9 million judgment for fraudulent prescription drug charges to Medicare. Initially, the penalty issued was $95 million (Stempel, 2025). In 2014, a former head actuary for Medicare Part D at Aetna initiated a whistleblower case, accusing CVS Caremark of causing health insurers to file false and inflated claims to the Centers for Medicare and Medicaid Services (CMS), while paying Rite Aid and Walgreens pharmacies less. The judge explained that CVS knowingly manipulated drug pricing to its financial benefit. Due to the motivations and intent of CVS, Judge Goldberg, using the False Claims Act, tripled the $95 million and added a $4.87 million civil fine. 

CVS is being admonished for causing fiscal harm to the government via CMS, as well as weakening public trust in the CMS. Judge Goldberg wrote, “CMS relies on companies like Caremark to truthfully and accurately report Part D drug prices," he wrote. "Caremark's conduct broke CMS's trust, and as a result, the public's trust in CMS." In the decision, Judge Goldberg specifically spelled out, “ Caremark devised a scheme to earn hidden spread or indirect profit on Part D purchases, and in the process, caused CMS to over-subsidize prescription drug costs to the tune of some $95 million. When CMS and other industry participants asked questions, Caremark consistently concealed the true nature of its scheme”. In addition to this case, CVS is appealing a separate $948.8 million judgment against its Omnicare unit, issued by a Manhattan federal judge in July, over allegations of fraudulent billing.

Photo Source: Review of Optometric Business

This pattern of profit-motivated questionable behavior is additional reasoning for why CVS’s initial decision not to cover Yeztugo is causing concern among many stakeholder groups. Yeztugo is a way to ensure adherence, given that it is only administered twice a year. It is crucial to increase the possibility of preventing HIV acquisition among those at high risk, not reduce it. Prevention reduces health care expenditures for the system and the individual. 

Stakeholders like Brian Hujdich, Executive Director at HealthHIV, explain the quandary: “It’s hard to reconcile Franklin’s wisdom together with CVS’s decision. Long-acting PrEP injectables could prevent unnecessary transmission, medical costs, and sick days, while reducing the time and effort required to stay protected. They can also help minimize situations where stigma commonly shows up — whether internal, like the stress of daily pill-taking, or external, like repeated pharmacy pickups and clinic visits — while supporting people to stay healthy.”

[1] Beasley, D. (2025, August 21). CVS holds off adding Gilead’s new HIV prevention shot to drug coverage lists. Retrieved from https://www.reuters.com/business/healthcare-pharmaceuticals/cvs-holds-off-adding-gileads-new-hiv-prevention-shot-drug-coverage-lists-2025-08-20/

[2] Bingham, A., Shrestha, R. K., Khurana, N., Jacobson, E. U., & Farnham, P. G. (2021). Estimated Lifetime HIV-Related Medical Costs in the United States. Sexually transmitted diseases, 48(4), 299–304. https://doi.org/10.1097/OLQ.0000000000001366

[3] Gilead Sciences. (2025, June 18). Press Release: Yeztugo® (Lenacapavir) Is Now the First and Only FDA-Approved HIV Prevention Option Offering 6 Months of Protection. Retrieved from https://www.gilead.com/news/news-details/2025/yeztugo-lenacapavir-is-now-the-first-and-only-fda-approved-hiv-prevention-option-offering-6-months-of-protection#:~:text=In%20the%20PURPOSE%202%20trial,with%20once%2Ddaily%20oral%20Truvada

[4] Kansteiner, F. (2025, August 21). For now, CVS declines to cover Gilead's long-acting HIV PrEP treatment Yeztugo. Retrieved from https://www.fiercepharma.com/pharma/now-cvs-declines-cover-gileads-twice-yearly-hiv-prep-treatment-yeztugo

[5] Stempel, J. (2025, August 20). CVS unit must pay $290 million in drug whistleblower lawsuit, judge rules. Retrieved from https://www.reuters.com/legal/government/cvs-unit-must-pay-290-million-drug-whistleblower-lawsuit-judge-rules-2025-08-20/#:~:text=In%20a%20Tuesday%

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.